Top tips on how to address the topic of HIV testing and prevention of transmission with patients
HIV may be seen as one of this century’s great medical success stories. When the infection was first classified in 1986,1 progression from HIV to AIDS, and eventual death, was almost inevitable. Three decades later, the majority of people living with HIV will live normal lives. Sadly, however, we believe that around 6% of people who have HIV remain undiagnosed.2 These people may be unlikely to attend a sexual health clinic and may not see themselves as being at risk of HIV.
HIV tests are now being more widely offered in NHS settings, particularly in high-prevalence areas. However, in order to find these undiagnosed people and achieve the government target of no new HIV diagnoses in the UK by 2030,3 HIV specialists are asking all health professionals to consider opportunities to offer testing to their patients. Here are my 10 top tips for how you might discuss HIV testing and prevention in your practice area.
1 Promote the positives
HIV is no longer a terminal illness. With early diagnosis and effective treatment, people living with HIV (PLWH) can expect to have a normal life expectancy and few negative effects from the illness.4 Antiretroviral treatment now reduces the HIV viral load within the body to a point where it is undetectable. Not only does this mean PLWH remain well, it also prevents them from transmitting HIV to anyone else (see tip 7). In people who are planning pregnancy, knowing their HIV status can enable them to access preventive treatment and therefore protect their child.
2 Be aware of stigma
Unfortunately, much stigma and misinformation still exists around HIV. As health professionals we have a responsibility to educate ourselves so we can share evidence-based information with our patients. Although some activities carry a higher risk of HIV, anyone from any background or sexuality can contract HIV. Someone who has same-sex partners is not automatically at ‘high risk’, and conversely, just being in a heterosexual relationship doesn’t mean someone is at low risk. Offering testing to all patients regardless of background helps to reduce the stigma and increases the likelihood of finding people living with undiagnosed HIV.
3 Be realistic about risks
Some people might be incredibly worried about their risk of contracting HIV despite engaging in low-risk activities, while others may be quite blasé about the risks they are taking. There can be a fine line between scaring patients and helping them reduce risks.
The rate and risk of HIV transmission is dependent on both the activity of concern and the HIV prevalence among the parties involved. Detailed advice for calculating risks can be found in British HIV association (BHIVA) guideline on post-exposure prophylaxis.5 Understanding and being realistic about risks can be helpful when discussing harm-reduction strategies with our patients.
4 Act early
Early diagnosis and treatment are key factors influencing the likelihood of a good outcome for someone living with HIV.4 Once the person is on treatment, the virus will be suppressed. This means it cannot replicate or destroy CD4 cells – the white blood cells that fight infection – meaning the immune system does not become compromised. It also means that the person has no freely circulating virus, so HIV cannot be passed to partners. Anyone starting a new relationship or who regularly has new sexual partners should be encouraged to test for all STIs.
5 Be PrEPared
Although condoms are very effective and protect against other STIs as well as HIV, not everyone remembers or has the agency to use them every time they engage in sexual contact. There is now a treatment known as PrEP (Pre-Exposure Prophylaxis) which can be taken daily, or as event-based treatment taken before and after sex. PrEP is highly effective at preventing HIV transmission.6,7 It is available free from most NHS sexual health services. If your patient discloses that they are engaging in higher-risk activities (such as unprotected anal sex with people from high prevalence groups) or has a partner who is HIV positive and not on treatment, they may benefit from being offered PrEP treatment.
6 Think PEP
PEP (Post Exposure Prophylaxis) is 28 days of HIV prevention treatment that can be taken after having unprotected higher-risk sex with someone who may be HIV positive. It needs to be started within 72 hours of the sex (the earlier the better). PEP can be accessed from sexual health clinics, and also from A&E departments out of hours. It can have some unpleasant side-effects, such as nausea and diarrhoea, but is highly effective at preventing HIV seroconversion.8
7 ‘Undetectable equals Untransmittable’ (U=U)
The global health community has coined the slogan ‘U=U’. This helps promote the fact that, if someone is HIV positive, has been on antiretroviral treatment for six months and has an undetectable viral load, there is no risk of their passing it on to anyone they have sex with regardless of the sexual activity or whether a condom is used.9 The earlier we diagnose people with HIV, the sooner we can start treatment and prevent transmission to others.
8 Ask for advice
If you think a patient would benefit from some more discussion around HIV, whether they are reluctant to test, need to explore risk reduction or want more information about HIV, most sexual health clinics have a health adviser service that can take referrals from other agencies. Charities like Terrence Higgins Trust, NAM and I Want PrEP Now are also useful places to signpost patients, or to access evidence-based information (see Useful websites, below).
9 Look out for symptoms
In the early stages of HIV infection, patients can experience ‘classic’ viral symptoms. A typical presentation of HIV seroconversion would be fever, rash and sore throat. As HIV progresses and begins to attack immune cells, symptoms can vary widely and patients may present in general practice, or to a specialist service. Some indicator conditions may be very common, such as pneumonia or generalised lymphadenopathy.10 In any condition not responding to the usual treatment, it is worth considering HIV as a differential diagnosis.
10 Make it routine
When a patient attends for routine blood tests, to discuss contraception or for cervical screening, these are ideal opportunities to offer routine HIV testing. Separate counselling is not required, and the conversation can be as simple as: ‘While I am doing your blood test, is it ok if I add an HIV test in too? It won’t require any extra needles.’ The majority of patients are happy to be tested for HIV when having other blood tests done, and many assume it is done routinely anyway. Some A&E departments are trialling routine HIV testing of all patients. Increasing testing opportunities will help to reduce stigma, identify undiagnosed individuals and hopefully help us reach the target of no new HIV diagnoses by the year 2030.
Jodie Crossman is nurse team leader at Brighton and Hove Sexual Health and Contraception Service and chair of the British Association for Sexual Health and HIV nurses group
References
- Coffin J et al. What to call the AIDS virus? Nature 1986;321:10 Link
- Presanis A et al. Trends in undiagnosed HIV prevalence in England and implications for eliminating HIV transmission by 2030: an evidence synthesis model. Lancet Public Health 2021;6:e739-e751. Link
- Terrence Higgins Trust. UK Government to commit to ending new HIV transmissions in England by 2030. January 2019. Link
- May M. Better to know: the importance of early HIV diagnosis. Lancet Public Health 2017;2:e6-e7. Link
- British HIV Association. UK guideline for the use of HIV post-exposure prophylaxis. 2021. Link
- British HIV Association. BHIVA/BASHH guidelines on the use of HIV pre-exposure prophylaxis (PrEP) 2018. Link
- Medical Research Council. The Proud Trial. Link
- Siedner M et al. HIV post-exposure prophylaxis (PEP). BMJ 2018;363:k4928 Link
- National AIDS Map. NAM endorses Undetectable equals Untransmittable (U=U) consensus statement. February 2017. Link
- EUROtest. HIV Indicator Conditions: Guidance for implementing HIV testing in adults in health care settings. Link
Useful websites
